Harris GE Siemens
CTisUS Sponsers
Pancreas

Ipmn

  • "Prediction of the pathologic subtypes of pancreatic IPMNs by CT is limited. Predominant main pancreatic duct involvement and a wide connection of a side branch lesion with the main pancreatic duct are the only CT findings that can be used to predict the pathologic subtype of pancreatic IPMN (carcinoma)."

    Pancreatic Intraductal Papillary Neoplasms: Role of CT in Predicting Pathologic Subtypes
    Gupta R et al.
    AJR 2008; 191;1458-1464

  • IPMN: Histologic Characterization
    - Adenoma
    - Borderline malignancy
    - Moderate dysplasia
    - Carcinoma in situ
    - Invasive carcinoma
    - Progression may take 5 years or more

  • "A diameter of the main pancreatic duct (MPD) of 6.0 mm or more, an abnormal attenuating area in the surrounding parenchyma,and a mural nodule in the MPD or in any associated cystic lesion of 3 mm or larger support the diagnosis of malignancy of the intraductal papillary neoplasm."

    Intraductal Papillary Mucinous Neoplasm of the Pancreas: Assessment of the Likelihood of Invasiveness with Multisection CT
    Ogawa H et al.
    Radiology 2008; 248:876-886

  • "Multiphase contrast enhanced CT with a multisection CT scanner is helpful for distinguishing among adenoma, noninvasive carcinoma, and invasive carcinoma in patients with IPMN and such a distinction provides valuable information to assist the clinician in guiding patient treatment."

    Intraductal Papillary Mucinous Neoplasm of the Pancreas: Assessment of the Likelihood of Invasiveness with Multisection CT
    Ogawa H et al.
    Radiology 2008; 248:876-886

  • "Multisection CT is useful for distinguishing among adenoma, noninvasive carcinoma and invasive carcinoma in patients with IPMN."

    Intraductal Papillary Mucinous Neoplasm of the Pancreas: Assessment of the Likelihood of Invasiveness with Multisection CT
    Ogawa H et al.
    Radiology 2008; 248:876-886

  • "Computed tomography findings suspicious for tumor recurrence include enlarging mass (either solid,cystic or both), progressive duct dilatation, or extrapancreatic disease."

    Recurrence Patterns of Intraductal Papillary Mucinous Neoplasms of the Pancreas on Enhanced Computed Tomography
    Landa J et al.
    J Comput Assist Tomogr 2009;33: 838-843

  • IPMN: Patterns of Recurrence
    - Enlarging mass at resection site
    - New mass developing in remaining gland
    - Progressive duct dilatation
    - Extrapancreatic disease
  • "Allen and Brennan proposed that selected patients with mucinous cysts without a solid component and of less than 3-cm diameter can be safely followed because the risk of malignancy approximates the risk of mortality from surgical resection."

    Prevalence of Unsuspected Pancreatic Cysts on MDCT
    Laffan TA, Horton KM, Fishman EK, Hruban RH
    AJR 2008;802-807
  • "CT falls short of MRCP in detecting a ductal connection, estimating main duct involvement, and identification of small branch duct cysts. These factors influence diagnostic accuracy, cancer risk stratification and operative strategy."

    CT vs MRCP:Optimal Classification of IPMN type and Extent
    Waters JA et al.
    J Gastrointest Surg (2008) 12:101-109
  • "Of 214 patients treated with IPMN(1991-2006), 30 had preoperative CT and MRCP. Of these, 18 met imaging study criteria."

    CT vs MRCP:Optimal Classification of IPMN type and Extent
    Waters JA et al.
    J Gastrointest Surg (2008) 12:101-109
    comment: only axial CT used and to study duct CPR and 3D are ideal. Also study over many types of CT
  • "CT is helpful in the differentiation of in situ and invasive IPMN. Classic vascular invasion criteria lead to the overestimation of surgical tumor unresectability in patients with malignant IPMN."

    Malignant Intraductal Papillary Mucinous Neoplasm of the Pancreas: In Situ versus Invasive Carcinoma-Surgical Resectability
    Vullierme MP et al.
    Radiology 2007;245:483-490
  • "Radiographic features that correlated with malignancy were presence of a solid component, main pancreatic duct dilatation, common bile duct diltation, and lymphadenopathy. Twenty seven of 31 (87%) patients with malignant lesions had at least one radiographic feature concerning for malignancy."

    Risk of Malignancy in Resected Cystic Tumors of the Pancreas =3cm in Size:Is it Safe to Observe Asymptomatic Patients? A Multi-Institutional Report
    Lee CJ et al.
    J Gastrointest Surg (2008) 12:234-242
  • "Based on retrospective analysis, this multi-institutional review of resection data of small cystic lesions from high volume centers suggests that a group of patients with a low risk of malignancy can be identified and be safely followed in accordance with the current consensus guidelines."

    Risk of Malignancy in Resected Cystic Tumors of the Pancreas =3cm in Size:Is it Safe to Observe Asymptomatic Patients? A Multi-Institutional Report
    Lee CJ et al.
    J Gastrointest Surg (2008) 12:234-242
  • "Pancreas protocol CT imaging appears to be a better predictor of resectability compared with EUS. EUS accuracy is affected by the presence of biliary stents."

    Endoscopic Ultrasound and Computed Tomography Predictors of Pancreatic Cancer Resectability
    Bao PQ et al
    J Gastrointest Surg (2008) 12:10-16
  • Cystic Pancreatic Tumors: Features For Low Risk of Malignancy

    - Asymptomatic patient
    - Size under 3 cm
    - Main pancreatic duct under 6 mm
    - No solid component (mural nodule) within or associated with the cystic lesion
    - No evidence of adenopathy
    - No common bile duct dilatation
  • "Radiographic features that correlated with malignancy were presence of a solid component, main pancreatic duct dilatation, common bile duct diltation, and lymphadenopathy. Twenty seven of 31 (87%) patients with malignant lesions had at least one radiographic feature concerning for malignancy."

    Risk of Malignancy in Resected Cystic Tumors of the Pancreas =3cm in Size:Is it Safe to Observe Asymptomatic Patients? A Multi-Institutional Report
    Lee CJ et al.
    J Gastrointest Surg (2008) 12:234-242
  • "Based on retrospective analysis, this multi-institutional review of resection data of small cystic lesions from high volume centers suggests that a group of patients with a low risk of malignancy can be identified and be safely followed in accordance with the current consensus guidelines."

    Risk of Malignancy in Resected Cystic Tumors of the Pancreas =3cm in Size:Is it Safe to Observe Asymptomatic Patients? A Multi-Institutional Report
    Lee CJ et al.
    J Gastrointest Surg (2008) 12:234-242
  • "Our results suggest that by combining data from both CT and EUS, a clinically relevant scoring system can be utilized to help select appropriate interventions and therapy for patients with pancreatic cancer."

    Predicting Unresectability in Pancreatic Cancer Patients: The Additive Effects of CT and Endoscopic Ultrasound
    Yovino S et al.
    J Gastrointest Surg (2007) 11:36-42
  • "Arterial dominant phase CT is useful for detecting invasive carcinoma derived from IPMNs and is an effective followup method."

    Invasive Carcinomas Derived From Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Long term Follow-up Assessment with CT Imaging
    Yamada Y et al.
    J Comput Assist Tomogr 2006;30:885-890
  • IPMN

    - 1. IPMN Adenoma
    - 2. IPMN Borderline
    - 3. IPMN Carcinoma in situ
    - 4. IPMN Invasive carcinoma
    - A. Colloid Carcinoma-Muc 2
    - B. Ductal Carcinoma- Muc 1
  • Intraductal Papillary Mucinous Neoplasm

    - 1.Proliferation of mucinous epithelial cells lining pancreatic ducts- arranged in papillary patterns.
    - 2. Intraluminal accumulation of mucin and cystic dilatation of ducts.
    - 3. Spectrum of architectural atypia from benign to malignant.
  • IPMN

    - 4. 1/3 of cases associated with invasive carcinoma.
    - 5. Communicate with pancreatic duct, ( unlike MCN ).
    - 6. No ovarian stroma.
    - 7. Mucin may be seen pouring into duodenum from patulous orifice of pancreatic duct.
  • - 1.Proliferation of mucinous epithelial cells lining pancreatic ducts- arranged in papillary patterns.
    - 2. Intraluminal accumulation of mucin and cystic dilatation of ducts.
    - 3. Spectrum of architectural atypia from benign to malignant.
  • Guidelines

    - 1. Asymptomatic cystic lesions without main duct dilatation [> 6 mm], those without mural nodules, and those < 30 mm in size have a low risk of progressing to invasive cancer in near-term [ 12 –to 36 month] followup.
    - 2. Yearly followup if lesion is <10 mm in size. 6-12 month follow-up for lesions 10-20 mm. 3-6 month followup for lesions >20 mm.
    - 3. Interval can be lengthened after 2 yrs of no change
    - 4. Appearance of sx attributable to the cyst [eg pancreatitis], presence of intramural nodules, cyst size > 30 mm, or dilatation of pancreatic duct >6mm are indications for resection.
  • Question #3 - Are there any endorsed criteria for conservative follow-up of a cystic pancreatic lesion?

    - Tanaka M et al. International Consensus Guidelines for Management of Intraductal Papillary Mucinous Neoplasms and Mucinous Cystic Neoplasms of the Pancreas. Pancreatology 2006; 6:17-32.
    - Consensus of the Working Group of the International Association of Pancreatology.
  • Conclusions from recent studies

    - Commonest small cysts are MCN, IPMN, and serous.
    - Very few pseudocysts in absense of pancreatitis.
    - Fewer than 5% of incidentally detected pancreatic cysts <2cm are malignant.
    - Patient’s choice: Follow, Bx under US, surgery.
    - General consensus:
    - 1. Under 2 cm observe.
    - 2. >2cm Young and middle-aged resect.
    - 3. >2cm older and less fit. Endoscopic US with fine needle aspiration, [ 40-50% sensitivity, 99+% specificity ]. Resect if mucin, high CEA, mucinous epithelium, malignant cells, or neuroendocrine cells.
  • The natural history of the incidentally discovered small simple pancreatic cyst; long term follow-up and clinical implications

    - Handrich SJ et al. AJR 2005; 184: 20-23. Mayo Clinic.
    - <2.0 cm cysts dx by sonography or CT 1985-1996.
    - 79 pts. 49 adequate follow-up.
    - 13 [ 59% ] no change or smaller. Mean size 8 mm, mean follow-up 9 years.
    - 9 [ 415 ] enlarged. Mean 14 mm to 26 mm. Mean follow-up 8 years. One pt operated on- pseudocyst.
    - 27 clinical follow-up or response to questionaire. Mean follow-up 10 years. None developed pancreatic disease.
    - 18 patients died. No suggestion of pancreatic disease.
    - 12 patients lost to follow-up.
  • Pancreatic cysts 3 cm or smaller: How aggressive should treatment be?

    - Sahani DV et al Radiology 2006; 238: 912-919. Mass General
    - 510 pts with cysts 1998-2004. 122 pancreatitis excld. 313/388 {80.6%} <3cm.
    - 86 patients in study with adequate data. Aged 24-89 years.
    - 48 surgery vs 38 non surgical.
    - 75 benign, 8 borderline malignant, 3 ca in situ.
    - Results of surgery: 37 benign MCN 13, IPMN side branch 14, serous 3, pseudocyst, cystic neuroendocrine 2, lymphoepithelial cyst 1, unclass 2 11 malignant
    - 8 borderline : 6 side-branch, 2 MCN. 3 ca in situ: 2 side-branch, 1 MCN.
    - 38 pts followed, all had US bx -1 later developed side-branch IMN with ca in situ.
  • Cystic pancreatic neoplasms- Observe or operate?

    - Spinnelli KS et al. Annals of Surgery 2004; 239: 651-659. U.Wisconsin. 1995-2002.
    - 290 cysts 1.2%. 132 hx pancreatitis thus, 168, 0.7% incidence of presumed neoplastic cysts.
    - 79 patients followed -16 months mean.
    - 15 increased in size [ 19% ]
    - 47 no change in size [ 59% ]
    - 17 decrease in size [ 22% ]
    - 49 had surgery
    - 14 benign 10 serous, 2 SPEN, 1 lymphoep, 1 simple cyst
    - 25 premalignant 16 MCN, 5 IPMn, 4 cystic neuroendocrine
    - 10 malignant 7 IPMN with Ca, 3 MCN
    - Recommend surgery if symptomatic, increasing, or fit older pts, since 60% of cysts in pts over 60 were malignant.
  • "Pathologic analysis revealed carcinoma in situ in seven patients (19%) and invasive carcinoma in 15 patients (42%) arising from the IPMN. With invasive carcinoma, the size of the tumor in branch duct type and combined type, and the caliber of the main pancreatic duct were significantly larger compared with the lesions without invasive carcinoma (4.7 +/- 1.7 cm vs 2.6 +/- 1.4 cm [p = 0.0007] and 9.3 +/- 5.5 mm vs 4.6 +/- 4.1 mm [p = 0.006], respectively)."

    MDCT of intraductal papillary mucinous neoplasm of the pancreas: evaluation of features predictive of invasive carcinoma
    Kawamoto S et al.
    AJR 2006 March;186(3):687-695.
  • "The use of high resolution axial, multiplanar reformatted, and three dimensional reformatted images as demonstrated by Kawamoto et al using 16 slice MDCT improves diagnostic performance and enables depiction of the connection between the cystic lesions of IPMN and the pancreatic duct."

    Stoupis C (commentary)
    RadioGraphics 2005; 25:1468-1470
  • Intraductal Papillary Mucinous Neoplasms of the Pancreas

    - Dilated main pancreatic duct
    - Diffuse or multifocal involvement
    - Presence of a large mural nodule or a solid mass
    - Large size of the mass
    - Obstruction of the common bile duct
  • Intraductal Papillary Mucinous Tumor (IPMN): Facts

    - Equal frequency men and woman
    - Usually detected in 6th and 7th decade
    - Commonly associated with dilated pancreatic duct
    - Lesions may be multiple and variable in size
  • Intraductal Papillary Mucinous Tumor (IPMN): Facts

    - Initially referred to as mucin producing pancreatic neoplasms
    - May be incidental finding or patients present with pancreatitis like symptoms
    - Up to 60% occur in the head/uncinate process
  • Cystic Endocrine Tumors

    - Insulinomas
    - Gastrinomas
    - Glucagonomas
    - Non-functioning tumors
  • IPMN: facts

    - Main or side branch duct dilatation common
    - Most common in uncinate
    - Can be multiple throughout the pancreatic gland
  • "The use of high resolution axial, multiplanar reformatted, and three dimensional reformatted images as demonstrated by Kawamoto et al using 16 slice MDCT improves diagnostic performance and enables depiction of the connection between the cystic lesions of IPMN and the pancreatic duct."

    Stoupis C (commentary)
    RadioGraphics 2005; 25:1468-1470
  • Intraductal Papillary Mucinous Neoplasms of the Pancreas

    - Dilated main pancreatic duct
    - Diffuse or multifocal involvement
    - Presence of a large mural nodule or a solid mass
    - Large size of the mass
    - Obstruction of the common bile duct
  • "Preoperative multidetector CT can help predict the presence of invasive carcinoma associated with IPMN."

    Intraductal Papillary Mucinous Neoplasm of the Pancreas: Can Benign Lesions Be Differentiated from Malignant Lesions with MDCT?
    Kawamoto S, Horton KM, Lawler LP, Hruban RH, Fishman EK
    RadioGraphics 2005; 25:1451-1470
All images on this site are © 2012 Elliot K. Fishman, MD.